<br /> By Sri.K Gheevarghese, President <br /> <br /> <br /> The complaint filed u/s. 12 of the Consumer Protection Act.<br /> The complaint in brief is as follows:<br /> <br /> The complainant is an Insurance Policy Holder of Mediclaim which covers the family members from 13.2.06 to 12.2.07 paying the premium amount Rs.6,643/-. The complainant was a student of 12th standard during the period of policy and attained majority on 20.9.06. During the tenure of a studentship the complainant was a member in the school football team and sustained injury on knee while playing football. After appearing the examination due to pain in the region of knee the complainant underwent treatment at Sree Ramachandra Medical Centre in Chennai on 10.4.05. Medical examination were conducted and the complainant was diagnosed as Osteod Osteoma. The pattern of different tests and treatments cost the complainant to spent Rs.1,25,000/-. The mediclaim policy was Rs.1,00,000/- the claim of the complainant was repudiated and a letter was sent to the father of the complainant on 13.6.06. The claim of the complainant with documentary evidence was also rejected, on the ground that the disease was pre existing. The complainant or his parents had no knowledge of any disease which was pre- existing on the complainant. The complainants entitled to get Rs.1,00,000/- from 13.6.06 with interest at the rate of 12% interest . The act of the opposite party is absolutely deficiency in service. There may be an order directing the opposite party to pay the complainant Rs.1,00,000/- with 12 % interest from 13.6.06 onwards.<br /> <br /> 2. The opposite parties filed version. The version in short is as follows:- The mediclaim insurance policy issued to the complainant is admitted. The contentions of the policy is as such that the policy covers the hospitalization expenses which is reasonably and necessarily incurred by the party. As per the medical records the complainant was affected of trauma to right knee 8 months back. On verification of the treatment and the request for claim shows that the complainant was admitted in Sree Ramachandra Medical Centre Chainnai on 10.4.06 for the removal of a osteoma tumour on the middle of the right Femur bone. The complainant had the pain in the region of right knee since over a month which itself shows that within 30 days of inception to the policy, the complainant was affected of illness. The tumour of osteoid osteoma will not develop within short period of 1 or 2 months. Terms and conditions of the policy is such that if the insured contracted any disease within 30 days from the inception, the insurer is not liable to pay the compensation and the policy was repudiated on that ground. There is no deficiency in service on the part of the opposite parties. The repudiation of the claim is strictly complied with the terms and conditions of the policy alone.<br /> <br /> 3. Points in consideration are as follows:<br /> 1) Is there any deficiency in service on the part of the opposite party?<br /> 2) Relief and cost?<br /> <br /> 4. Point No.1: The complainant filed proof affidavit . Ext. A1to A11 are marked as documents to support the facts. The opposite party swear their contentions and filed affidavit. Ext. B1 to B9 are the documents filed on their side. The complainant has given the oral testimony apart from the documents produced. The case of the complainant is that the complainant is entitled for the benefit of the Medicalim family insurance. The complainant had undergone treatment for Osteod Osteoma. The claim of the opposite party is that the insured contracted illness within 30 days from the inception to the policy and also for the reason that the complainant had pree existing decease when became the policy holder. Ext. A2 is the discharge summory of Sree Ramachandra Medical Centre. The final diagnosis report of the same shows that the complainant is having the diseases Osteod Osteoma in the right femer. The policy covers the period 13.2.2006 to midnight of 12.2.07. The family members are covered under the policy. The complainant underwent treatment for which Rs.1,02,432/- was spent apart from other expenses. In oral testimony of the complainant it is stated that the complainant <br /> belongs football team of the school and he had met with a trauma in the right knee. The repudiation of the claim was as per the exclusion clause 4.1 and 4.2 of the policy. The complainant had the first consultation of the disease on 10.4.06. The commencement of the policy was on 13.2.06 for a period of one year. The claim was rejected on the ground that the complainant had the pre- existing disease at the time of inception to the policy and he had the pain on right thigh in the last 8 months. Neither the complainant nor the parents were aware of the disease osteod osteoma when the complainant was entered into scheme of the insurance. The complainant was not aware of the osteod osteoma and it was only latter diagnosed and that too was only after one month. The Insured has no conscious knowledge of the disease. In New India Insurance Company Limited Vs. Mrs, Marry Jaine Govias and others (2007 CTJ) Pg.138 Vol.15, The Hon. National Commission held that in the treatment within 30 days of the commencement of policy cannot be construed to be that the disease was within knowledge of the insured. Even if the insured is admitted for a treatment if the particular disease is not known to the patient the benefit of the exclusion clause cannot be entertained. The repudiation of the claim by the complainant is absolutely a deficiency in services. Point No.1 is found in favour of the complainant.<br /> <br /> 5. Point No.2; Policy covers risk of maximum Rs.1,00,000/-. Complainant had an expenses of Rs.1,02,432/- as per Ext. A3. The maximum amount which can be claimed as per the policy amounts to Rs. 1,00,000/-. The complainant is to be paid the insured sum along with cost. Point No.2 is found as such.<br /> <br /> In the result complaint is partly allowed the opposite party is directed to pay the complainant Rs.1,00,000/- (Rupees One lakh only) with 12 % interest from 13.6.06 till payment. The opposite party is also directed to give cost of Rs. 1,000/- to the complainant. This is to be complied with within one month from the date of receiving this order.<br /> <br /> Pronounced in open forum on this the day of 31st October, 2008.<br /> PRESIDENT: Sd/-<br /> <br /> MEMBER Sd/-<br /> <br /> MEMBER Sd/-<br /> <br /> A P P E N D I X:<br /> <br /> Witness examined for Complainant:<br /> PW 1 Jikku Seban George Student<br /> Witness examined for opposite party:<br /> OPW 1 K.P. Raghavan Manager<br /> <br /> <br /> Exhibits marked for complainant <br /> A1 Copy of mediclaim policy<br /> A2 Copy of case sheet.<br /> A3 Copy of the case sheet<br /> A4 Letter sent by Medi Assist Dt.13.6.06<br /> A5 Letter Dt. 25.7.2006<br /> A6 Letter Dt 3.11.04<br /> A7 Medical certificate Dt. 15.7.2006<br /> A8 Certificate Dt. 15.7.2006<br /> A9 Participation Certificate<br /> A10 Certificate of merit<br /> A11 Copy of Certificate <br /> Exhibits marked for opposite party.<br /> B1 Mediclaim Insurance Proposal form Dt. 10.2.06<br /> B2 Copy of policy with terms and conditions Dt. 13.2.06<br /> B2 (a) Insurance policy <br /> B3 Claim form Dt. 8.5.06<br /> B4 Discharge summery Dt.14.4.06<br /> B5 CT Scan report Dt. 11.4.06<br /> B6 Letter Dt. 8.5.2006<br /> B7 Letter Dt. 13.6.2006<br /> B8 Reply notice Dt. 13.6.2006<br /> B9 Claim repudiation letter Dt. 3.11.06